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MARION—COUNTY PUBLIC WORKS <br /> BUILDING INSPECTION DIVISION <br /> 5155 Silverton Rd NE <br /> Salem OR 97305 <br /> (503) 588-5147 FAX(503) 588-7948 <br /> http:/fpnblicworks.co.marion.or.us/building/ <br /> SEPTIC TANK ABANDONMENT FORM <br /> THE SEPTIC TANK AT: /2 7' 9 eat, I <br /> r D <br /> /0.,•-e" <br /> ACTIVITY NUMBER: $ �� —f - 97&y' • <br /> WAS PUMPED BY: / <br /> .DEQ License# <br /> DALE TANK PUMPED: <br /> ENCLOSE A COPY OF THE PUMPING RECEIPT WITH THIS FORM. <br /> THE TANK WAS: <br /> [] REMOVED 7-A- <br /> - <br /> p . <br /> FILLED 'jib�-� <br /> (NOTE:The bottom of the tank should be perforated or cracked to prohibit the • <br /> accumulation of surface water in the tank) <br /> . FILL MATERIAL: <br /> [] REJECT SAND . <br /> [] BAR RUN GRAVEL <br /> • Dkr CRU -.! D 'OCK • • <br /> COMPANY NAME: / 6 C' " L "�-' �`'�- C �— <br /> SIGNED: . �-DA'Z'E: <br /> • <br /> MC S-02 <br /> rev:6/03 <br />